Elad Anter

Background: Acute pericarditis is an uncommon complication of thermal atrial fibrillation (AF) ablation, whereas milder pericardial inflammatory symptoms, typically pleuritic or positional chest pain, are more common and negatively affect post‐procedural recovery. Pulsed field ablation (PFA), a non‐thermal modality with tissue‐selective properties, may reduce collateral pericardial injury. We compared post‐procedural pericardial inflammatory symptoms and recovery after AF ablation using PFA vs. radiofrequency ablation (RFA). Methods: This single‐center observational study with prospective data collection included 150 patients undergoing catheter ablation for paroxysmal or persistent AF using focal PFA ( n = 75) or RFA ( n = 75). Patients were identified from the procedural workflow during the study period. Post‐procedural pericardial inflammatory symptoms, chest pain severity (5‐point scale), anti‐inflammatory therapy use, length of hospital stay, and biomarkers of inflammation (CRP) and myocardial injury (hs‐TnT) were assessed during hospitalization and structured post‐discharge follow‐up. Results: Baseline characteristics were similar between groups. Post‐procedural chest pain occurred more frequently after RFA than PFA (32% vs. 5.3%, p < 0.001), despite a significantly greater proportion of patients in the PFA group receiving lesion sets beyond pulmonary vein isolation (94.7% vs. 73.3%, p < 0.001). Anti‐inflammatory therapy was prescribed more frequently after RFA (20% vs. 2.7%, p = 0.001), and hospital length of stay was longer [2 (1–2) vs. 1(1–1) days, p = 0.03). Procedure duration was shorter with PFA (86 ± 36 vs. 122 ± 55 min, p < 0.001). Median hs‐TnT levels were higher after PFA [1288 (865–2137) vs. 1001 (652–1368] ng/L, p = 0.01), whereas CRP levels were similar [10.4 (4.9–23.3) vs. 10.5 (6.9–27.3) mg/L; p = 0.38]. Conclusions: PFA was associated with fewer post‐procedural pericardial inflammatory symptoms, reduced need for anti‐inflammatory therapy, and faster recovery compared with RFA. These findings suggest reduced pericardial irritation and improved patient‐centered recovery after AF ablation.

Recent advances in techniques, technologies and proven superiority over anti-arrhythmic drugs have made catheter ablation the cornerstone of management for atrial fibrillation (AF), which has shown a steady increase in prevalence in the ageing population worldwide. The aim of therapeutic interventions is to achieve stable sinus rhythm that would improve the quality of life and reduce the risk of AF-associated complications. Pulmonary veins (PVs) were first described as the source of initiation of ectopic triggers driving AF, which led to the establishment of PV isolation (PVI) as the most widely practiced procedure to treat AF. Antral PVI is still recognized as the stand-alone ablation strategy for newly diagnosed paroxysmal AF (PAF). However, in non-PAF patients, PVI seems to be inadequate and several adjunctive strategies, including ablation of left atrial posterior wall and non-PV triggers, AF mapping and ablation of rotors and drivers, ethanol infusion of vein of Marshall and renal denervation, etc. have been reported with mixed results. Recent trials have also documented the benefits of early rhythm control in preventing cardiovascular events in addition to slowing the progression of PAF to more persistent forms. Similarly, very late relapse of the arrhythmia after successful PVI has drawn attention to the critical role of non-PV triggers and highlighted their relevance as potential ablation targets during repeat procedures. Ablation technology is also under constant evolution with the introduction of non-thermal energy sources and new tools to create durable lesions. This review summarizes the indications, advancements, and future perspective of AF ablation.

Pulsed field ablation (PFA) has significant advantages over conventional thermal ablation of atrial fibrillation (AF). This first-in-human, single-arm trial to treat paroxysmal AF (PAF) assessed the efficiency, safety, pulmonary vein isolation (PVI) durability and one-year clinical effectiveness of an 8 Fr, large-lattice, conformable single-shot PFA catheter together with a dedicated electroanatomical mapping system. After rendering the PV anatomy, the PFA catheter delivered monopolar, biphasic pulse trains (5–6 s per application; ∼4 applications per PV). Three waveforms were tested: PULSE1, PULSE2, and PULSE3. Follow-up included ECGs, Holters at 6 and 12 months, and symptomatic and scheduled transtelephonic monitoring. The primary and secondary efficacy endpoints were acute PVI and post-blanking atrial arrhythmia recurrence, respectively. Invasive remapping was conducted ∼75 days post-ablation. At three centres, PVI was performed by five operators in 85 patients using PULSE1 (n = 30), PULSE2 (n = 20), and PULSE3 (n = 35). Acute PVI was achieved in 100% of PVs using 3.9 ± 1.4 PFA applications per PV. Overall procedure, transpired ablation, PFA catheter dwell and fluoroscopy times were 56.5 ± 21.6, 10.0 ± 6.0, 19.1 ± 9.3, and 5.7 ± 3.9 min, respectively. No pre-defined primary safety events occurred. Upon remapping, PVI durability was 90% and 99% on a per-vein basis for the total and PULSE3 cohort, respectively. The Kaplan–Meier estimate of one-year freedom from atrial arrhythmias was 81.8% (95% CI 70.2–89.2%) for the total, and 100% (95% CI 80.6–100%) for the PULSE3 cohort. Pulmonary vein isolation (PVI) utilizing a conformable single-shot PFA catheter to treat PAF was efficient, safe, and effective, with durable lesions demonstrated upon remapping.